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Endocarditis and Echocardiography - Unusual Participants in a Cesarean Delivery
Abstract Number: S3C-6
Abstract Type: Case Report/Case Series
Infective endocarditis (IE) is reported to complicate 1 in 100,000 pregnancies making it exceedingly rare (1). The mortality rate is high for both mother and fetus at 33% and 29% respectively (2) and requires aggressive interdisciplinary management for favorable outcomes. We present a patient with acute IE and subsequent severe mitral valve (MV) regurgitation presumed stable, however, rapid respiratory decompensation necessitated emergent cesarean section (C/S) and MV replacement (MVR).
LH is a previously healthy 24-year-old G1P0 woman at 31 weeks and 2 days gestation with an Enterococcus faecalis urinary tract infection, resultant bacteremia, acute IE, and severe MV regurgitation (MR). Acute decompensation in maternal respiratory status necessitated an emergent C/S and MVR. Two large-bore peripheral intravenous lines and an arterial line were placed and pre-induction epinephrine and norepinephrine infusions were started. Rapid sequence induction and intubation were performed with the patient in left uterine displacement followed by uncomplicated C/S delivery of neonate. Transesophageal echocardiography demonstrated preserved biventricular function with vegetation and leaflet destruction of the MV causing severe MR confirmed by holosystolic flow reversal in the pulmonary veins. Once hemostasis was obtained via IV Pitocin, a central line and pulmonary artery (PA) catheter were placed showing an initial mean PA pressure of 43mmHg. Full dose anticoagulation ensued with placement of a mechanical MV and reduction of the mean PA pressure to 24mmHg. The patient was discharged to home on postoperative day 18.
IE is very rare in parturients with a high mortality rate and a very dynamic course. Management requires effective planning, teamwork and communication among multiple medical specialties which was particularly difficult in this case due to LH’s rapid decompensation requiring emergent intervention. The combination of C/S and MVR poses incredible challenges for the anesthesiologist in balancing anesthetic technique, appropriate monitors, fluid management, and hemostasis with continued concerns for postpartum hemorrhage intra- and post-operatively and great risks to the mother and neonate.
1. Montoya ME, et al. Endocarditis during pregnancy. Southern Med J 2003; 96: 1156-1157.
2. Connolly C, et al. Infective endocarditis in pregnancy: Case report and review of the literature. Obstet Med. 2015;8(2):102-4.